mellss yr4 primary care hypertension
TRANSCRIPT
Amalina Aminuddin 0820121000 67
Treatment Management
Benefits and principles Benefits ? Principles 1. Improve long term survival and
quality of life2. Promote effective physician-patient
relationship3. Reduce level to 140/90mmHg or less4. Assess cardiovascular risk factors5. Instruct on non-drug treatments and
benefits6. Home BP monitoring for mild
hypertension with no target organ damage
7. Drug therapy given to those with high initial reading, target organ damage or failed non- drug measures
8. Careful selection of drug and appraisal of side effects vs. benefits
9. Avoid drug- related problems10. Aim for steady and graduated control11. Counter problems of patient non-compliance12. Be aware of factors that may contribute to
drug resistance
Patient education Reassurance Clear information Easy to follow instructions Correction of patient’s misconceptions Compliance ?
Non- pharmalogical management
When DBP at initial visit is 90-100mmHg and no organ damage, indicate 3 months without drugs.
Weight reduction Reduce excessive alcohol intake and
smoking Reduction of stress Reduce sodium intake Increase exercise Manage sleep apnoea
Pharmacological therapy
Failed genuine non-pharmalogical trial
SBP 140- 180 or DBP 90 – 110mmHg
Start with a single drug at low dose.
4–6 weeks period for apparent result
If ineffective, consider increasing dose /add another /substitute drug
Use only one drug from any one class at the same time.
Measure the BP at the same time each day.
WHEN TO TREAT : GUIDELINES
1) A or C or D2) If target not reached,
A+C or A +D3) If target not reached,
A+C+D
ACE inhibitor or ARB Calcium-channel
blocker thiazide Diuretic
STARTING REGIMENS
Thiazide diuretic Beta-blocker Calcium-channelblocker
ACE inhibitor
Typical examples
Hydrochlorothiazide12.5 mg dailyIndapamide 1.5 mg or 2.5 mg daily
Atenolol25–50 mg dailyMetoprolol50 mg dailyPropranolol40 mg daily
Amlodipine2.5 mg dailyDiltiazem 180 mg dailyNifedipine 30 mg dailyVerapamil 120–180 mg daily
Captopril6.25 mg bdEnalapril5 mg dailyARBIrbesartan150 mg dailyLosartan50 mg daily
Recommended in
•Heart failure (mild)•Older patients
•Anxious patient•Young patients•Angina•Postmyocardial infarction•Migraine
•Asthma•Angina•PVD•Raynaud phenomenon
•Heart failure•PVD•Diabetes•Raynaud
D B C A
Contraindication
•Type 2 diabetics•Hyperuricaemia•Kidney failure
•Asthma COPD•History of wheeze•Heart failure•Heart block
•Heart block •Heart failure (verapamil, diltiazem)
•Bilateral kidney artery stenosis•Pregnancy•Hyperkalaemia
Precautions
•Hypokalaemia•Thiazides + ACE inhibitors•Kidney failure
•Use with verapamil, ,NSAIDs,in smokers
•With b blockers and digoxin CCF
•Chronic kidney Disease• K-sparing diuretics and NSAIDs
Important side effects
•Rashes•Hypokalaemia•Hyponatraemia•Hyperuricaemia•Hyperglycaemia
•Fatigue•Insomnia•Bronchospasm•Cold extremities
•Headache•Flushing•Ankle oedema•Palpitations
• Cough• Dysgeusia• Hyperkalaemi
a• First dose
hypotension• Angioedema
Management
Mild hypertension Persistent SBP 140-159 or DBP between
90 -99 mmHg, without target organ damage.
Start lifestyle changes then, assess 5 year absolute CV riskRisk ( %) Management • Low
(10)• Maintain lifestyle changes for 6-12
months• Consider drug treatment if >
150/95 mmHg
• Moderate (10-15)
• Maintain lifestyle changes for 3-6 months
• Consider drug treatment if > 140/90 mmHg
• High (>15)
• Maintain lifestyle changes • Begin drug treatment
If BP is well controlled for several months to years, dose or number of drugs can be reduce.
Careful monitoring is mandatory.
Moderate hypertension Try lifestyle
changes Begin drug
treatment if fail If poor initial
response, prescribe2nd drug
Severe hypertension Check for hypertensive
complications May need to be hospitalize CCB with Beta blocker or ACEI
for urgent BP lowering
Hypertensive emergencies
Hypertensive encephalopathy, acute stroke,heart failure, dissecting aortic aneurysm, eclampsia, headache and confusion.
Hospitalised immediately for monitoring and treatment.
Same treatment as severe hypertension. Gradual BP lowering Sodium nitroprusside IV Magnesium sulphate ( eclampsia)
Isolated Systolic Hypertension
Frequently seen in elderly SBP ≥140 mmHg with DBP <90
mmHg Treated as classic hypertension. Commence non-pharmacological
therapy Lower SBP to 140 -160 mmHg
carefully Diuretics, calcium channel
blocking agents and ACE inhibitors.
Refractory Hypertension BP > 140/90mmHg despite maximum
dosage of two drugs for 3-4 months Review possible secondary causes
Drug-related causes: doses too low, inappropriate combinations, effects of other drugs (e.g. antidepressants, adrenal steroids, NSAIDs, oral contraceptives)
Poor compliance with therapy Renovascular hypertension Obesity Excessive alcohol or salt intake Kidney insufficiency and other undiagnosed causes of secondary hypertension Sleep apnoea
Refer to specialist ( no control and no obvious reason)
24-hour ambulatory monitoring.
Routine BP measurement for: Children of hypertensive parents ,those at risk of
secondary hypertension ,children with visual changes, headache, recurrent abdominal pain , and those on corticosteroids
The upper limits of normal BP:
ACEI/ CCB + Diuretics Avoid ACEI in post pubertal girls.
AGE (IN YEARS)
ARTERIAL PRESSURE (MMHG)
14–18 135/9010–13 125/856–9 120/805 or less 110/75
Hypertension In Children
Hypertension in Elderly
Treat isolated systolic hypertension May respond to non-pharmacological treatment.
Reduce dietary sodium Drug dosage—‘start low and go slow’.Treat as younger patient if > 70 years and in good health
Gradual reduction in BP Be aware of drug and drug interactions
GUIDELINES
First-line choice: indapamide /thiazide diuretic (low dose) Add K-sparing diuretic if hypokalaemia
Second line choice: ACE inhibitors or ARB
Other effective drugs (especially for isolated systolic hypertension): β-blockers (low dose) Calcium-channel blockers
SPECIFIC TREATMENT
Diabetes Mellitus Monitor patients for early signs of nephropathy Diabetics with persistent DBP >85 mmHg and
proteinuria need treatment. Treatment
Non-pharmacological treatments First-line choice:
ACE inhibitors or ARBs and calcium-channel blockers Suitable drugs choice:
Prazosin, hydralazine and methyldopa. Caution :Indapamide + ACE inhibitor Monitor proteinuria and kidney function
DBP >80 mmHg in late pregnancy is unacceptable.
Preferred drugs: methyldopa, labetalol,
and β-blockers. Diuretics and ACE
inhibitors should not be used.
Continue same treatment: patients whose BP is under control before surgery
Take parenteral treatment if oral medication affected by surgery
PREGNANCY SURGICAL PATIENTS
Use loop diuretic initially.
Drugs that can be used: β-blockers, Calcium-channel
blockers, Prazosin Methyldopa
Caution :ACE inhibitors
First-line treatment: ACE inhibitors and
diuretics. Other suitable drugs:
hydralazine–nitrate combination
methyldopa. Caution: Calcium-
channel blockers Avoid verapamil and β-
blockers
KIDNEY DISEASE HEART FAILURE
Recommended drugs: β-blockers Calcium antagonists
All except β-blocker
Avoid : Thiazide diuretics, Methyldopa, Reserpine β-blockers
Suitable agents: ACE inhibitors Calcium channel
blockers.
ISCHAEMIC HEART DISEASE ERECTILE DYSFUNCTION
OBSTRUCTIVE PULMONARY DISEASE
Can hypertension be overtreated? Excessive BP reduction can compromise
perfusion in vital organs. Avoid excessive BP reduction in acute
stroke, elderly and head injury. DBP <85 mmHg in ischaemic heart
disease raise the cardiovascular risk
Referance John Murtagh , Murtagh’s General
Practice, 5th edition, 2011, McGraw Hill Australian Pty Ltd.
http://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf